Insurer Held Accountable for Misleading Explanation of Policy to Elderly Traveller
Insurer Held Accountable for Misleading Explanation of Policy to Elderly Traveller
The information on this website is general in nature and does not take into account your objectives, financial situation, or needs. Consider seeking personal advice from a licensed adviser before acting on any information.
An elderly gentleman, who submitted a claim on behalf of his injured wife, has successfully resolved his dispute against his insurance company.
The Australian Financial Complaints Authority ruled in favor of the complainant, finding that he had been misled into thinking he had coverage.
The claim was initiated after the man's wife had a severe fall down a flight of stairs during their trip to Thailand. She sustained multiple injuries, including a fractured hip and head trauma, which required her to be hospitalized for more than three weeks. Additionally, to ensure a safe journey back to Melbourne, the claimant had to purchase a business class flight for his wife, allowing her to lie flat and minimize the risk of complications.
Zurich Australia denied the claim based on the policy's exclusion of overseas medical expenses for individuals over 80 years old. However, Zurich claimed to have offered an "upgrade" to the policy, providing medical coverage for individuals over 80, which the claimant did not opt for.
The complainant obtained the policy through a local branch of his bank, referred to as CB, which offered it as a benefit for specific credit card holders. At the time of purchasing the policy, both the complainant and his wife were 81 and 80 years old, respectively.
Making an effort to follow the correct procedure given his limited computer skills, Mr. E visited the local CB branch on June 30. He expected the staff to guide him through the application process for the policy.
Mr. E alleged that the CB staff failed to inform him about the need to "upgrade" the policy in order to ensure adequate coverage for medical expenses. He left the bank under the impression that he and his wife were appropriately insured, even receiving an email confirmation from the insurer stating that the policy had been activated.
AFCA considered the claimant's assertion that a bank teller, referred to as SH, had assisted him during the application process. Despite Zurich's objections, the ruling ombudsman agreed with Mr. E's account.
The ruling acknowledged that SH had neglected to disclose the requirement to "upgrade" the policy, necessary for the claimant and his wife to have coverage, despite the bank being aware of their age. It stated that although SH's actions were unintentional, CB caused the insured party to believe they had suitable coverage.
"Given CB's knowledge of the complainants' age, this omission should have been disclosed," AFCA stated.
"SH's oversight significantly contributed to Mr. E's unwitting failure to apply for the policy upgrade. Furthermore, this omission induced Mr. E to enter into an insurance contract that he believed provided adequate coverage. However, unbeknownst to him, the policy was essentially useless in terms of overseas medical expense coverage for both him and Mrs. E."
Zurich argued that CB employees were not authorized representatives and thus were unable to offer any advice on the credit card insurance being offered. However, AFCA dismissed this argument as an attempt by the insurer to absolve itself of CB's shortcomings, stating that the bank acted, at least partially, in the insurer's interest.
The decision mandates that Zurich accept the claim and provides a compensation of $4000 ($2000 for each complainant) for non-financial losses resulting from the insurer's claim denial and subsequent challenges.
"Throughout the claims process, the insurer's stance has unfortunately caused the complainants, particularly Mr. E, to feel accused of dishonesty," expressed AFCA.
"They also feel that their recollections have been questioned. Moreover, the insurer's position in this claim has been based on flimsy evidence."
Please Note: We do not endorse any specific products or companies. Some content is sourced from third parties, including press releases, and may not be independently verified for accuracy or completeness.
Gallagher's recent guidance for Australia's heavy vehicle sector identifies fatigue, inattention, distraction, and inappropriate speed as major contributors to truck incidents and related insurance claims. This analysis is based on recent crash data and regulatory expectations, highlighting the need for comprehensive risk management strategies within the transport industry. - read more
Hostplus, a leading Australian superannuation fund, has announced the extension of its group insurance partnership with MetLife Australia until June 2028. This strategic move aims to enhance the insurance benefits available to Hostplus members, reflecting the fund's commitment to providing comprehensive and cost-effective coverage. - read more
Nautilus Marine Insurance, a leading provider in Australia's marine insurance sector, has marked its 21st anniversary by unveiling a refreshed brand identity and expanding its team with strategic appointments. This evolution underscores the company's commitment to growth and its dedication to serving the marine community. - read more
Zurich Financial Services Australia has unveiled 'Prime One', a cutting-edge cyber insurance product designed to bolster the digital resilience of Australian businesses. Developed in partnership with Cowbell, a specialist in adaptive cyber and specialty insurance solutions, 'Prime One' leverages artificial intelligence to streamline the underwriting process, offering rapid and tailored coverage. - read more
The Australian government has announced substantial reforms to the National Disability Insurance Scheme (NDIS) as part of the 2026 federal budget, aiming to save more than $36 billion over the next four years. These changes are intended to curb the scheme's rapid growth and ensure its sustainability, while refocusing support on individuals with significant and permanent disabilities. - read more
Life insurance, a contract between an insurer and a policyholder, is designed to provide financial protection to loved ones in the event of the policyholder's death. For parents, this protection takes on a new level of significance. The birth of a child heralds a profound shift in priorities, with a focus on safeguarding the future of one's family. Hence, understanding life insurance options becomes a crucial aspect of responsible parenting. - read more
When it comes to life insurance, a pre-existing condition refers to any medical condition or illness that you have been diagnosed with before applying for a life insurance policy. - read more
For many millennials, navigating the complexities of personal finance and future planning can feel like a bewildering journey. Among these financial responsibilities, life insurance emerges as a paramount consideration. More than just a safety net, life insurance can be the cornerstone of a sound financial strategy, providing peace of mind for both the policyholder and their loved ones. - read more
Life insurance can seem complex at first, but understanding the basics can help demystify this important financial product. At its core, life insurance is a contract between you and an insurer, where the insurer promises to pay a designated beneficiary a sum of money upon your passing, in exchange for premium payments. - read more
The horizon of the insurance industry has undergone a transformative shift with the advent of digital technology. With a few clicks, consumers can navigate the once-complex world of insurance policies from the comfort of their home. The digital landscape for insurance services offers unprecedented access to information, comparisons, and instant communication, fostering a more empowered insurance client. - read more
Start Here !
Apply now for your free Insurance assessment and price comparisons!
Knowledgebase
Aggregate Limit: The maximum amount an insurer will pay for all covered losses during a policy period.
No comments yet. Be the first to share your thoughts.